No Clear Right Choice for Postextubation Support

Patricia Kritek, MD

High-flow oxygen was noninferior to noninvasive positive pressure ventilation for preventing reintubation.

During the last 2 years, we have seen a rapid rise in use of high-flow oxygen. Although its use is supported during the immediate postextubation period for patients at low risk for reintubation (NEJM JW Gen Med Apr 15 2016 and JAMA 2016; 315:1345 and 1354), this has not been studied in a high-risk population. Investigators in Spain randomized 604 mechanically ventilated patients to be extubated to 24 hours of either high-flow nasal cannula or noninvasive positive pressure ventilation (NPPV). All patients were deemed to be at high risk for reintubation, although criteria for this designation were quite inclusive, and only one risk factor was required (e.g., age, >65; body-mass index, >30; ≥2 comorbidities; intubation for >7 days).

Reintubation rates within 72 hours after extubation were similar in the NPPV and high-flow groups (19% vs. 23%); rates were even closer (16% vs. 17%) after nonrespiratory reasons for reintubation (e.g., return to the operating room) were excluded. Although not statistically significant, reintubations in the high-flow group appeared to increase after the first 24 hours, compared with the NPPV group. Median time to reintubation did not differ significantly between groups.

Comment:
This study doesn’t convince me that high-flow oxygen is the right choice for all patients at high risk for reintubation. Given the very inclusive definition of “high risk” and some imbalances in patient populations, we still don’t really know which patients are better or worse candidates for the different interventions. I’m also left with the question of whether 24 hours of support is the “right” amount. For now, I think the best strategy is to base the decision about postextubation support on the individual patient’s clinical picture and to include NPPV, high-flow oxygen, and standard oxygen therapy in the options.

Citation(s):
Hernández G et al. Effect of postextubation high-flow nasal cannula vs noninvasive ventilation on reintubation and postextubation respiratory failure in high-risk patients: A randomized clinical trial. JAMA 2016 Oct 18; 316:1565. (http://dx.doi.org/10.1001/jama.2016.14194)

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